To the best of our knowledge, this is the first qualitative study exploring perceptions about the interrelationships between antibiotic use, resistance development and environmental factors, i.e. physical, natural, social and behavioural factors. The views put forward here suggest that the possible contributors to antibiotics use/misuse and resistance development are - changes in the natural and physical environment, i.e. climate variability, pollution, physiography and population growth; socioeconomic environmental factors affecting health-seeking behaviour and noncompliance with medication; a lack of healthcare facilities and poor professional attitudes; and ineffective law enforcement in relation to drug dispensing, manufacture and disposal.
Changes in the natural and physical environment
According to Brown , there is a need to conduct qualitative studies in the area of environmental health to further understand how people perceive the relationship between environment and public health. Participants in our study perceived that ecological imbalances triggered by seasonal changes in weather conditions, such as temperature, precipitation and humidity; and pollution were responsible for the emergence and the re-emergence of diseases, which in turn influenced antibiotic prescriptions and antibiotic use. Our respondents perceived a seasonal pattern of occurrence of diseases e.g. skin infections and hence expected antibiotic prescriptions also to follow the same pattern. That infectious diseases show a seasonal pattern is well known. Models have demonstrated that small seasonal changes in host or pathogen factors may be sufficient to create large seasonal effects on disease incidence, which might be important particularly in the context of global environmental changes .
There is a general lack of studies on whether changes in weather conditions modify levels of antibiotic resistance. However, some studies from Europe and the United States have reported on geographical variation in antibiotic consumption and resistance, taking into account the influence of social and climatological factors [14–17], which was also mentioned by the participants in our study. If more studies are taken up in this area of research, and if they establish a clear-cut relationship between weather/seasonal changes, and occurrence of diseases, antibiotic prescriptions, and antibiotic resistance, although we cannot control weather or seasons, in anticipation of the impending calamities, governments and health systems can keep themselves ready with contingency plans to take up appropriate remedial/interventional measures.
Previous studies have shown that outdoor environmental air pollution from various sources, such as motor vehicles, industry, and neighbourhood-level solid waste burning, is associated with increased morbidity and mortality from respiratory infections in children and adults [18, 19]. Increased morbidity might lead to increased antibiotic prescribing, which in turn might lead to increased resistance. This kind of thoughts may have been in the minds of our participants, when they brought into discussion pollution as an environmental factor resulting into more infections, more prescriptions, and more resistance.
The impact of antibiotic use on the environment was also perceived by healthcare providers. One participant suggested that antibiotic contamination of the aquatic environment may be one of the reasons for the resistance found in waterborne bacteria, due to exposure to below-threshold concentrations in water. Studies have shown that antibiotics and antibiotic resistant bacteria are found in the aquatic environment [20, 21], however, very few studies  have looked at the impact of antibiotics in the aquatic environment on human health. Our interviewees believe that more studies in this area are essential from a public health perspective.
Socioeconomic environment and health-seeking behaviour
Participants in this study perceived that socioeconomic and behavioural factors, i.e. poverty; self-medication and non-compliance result in inappropriate use of antibiotics. This finding is consistent with the results of other studies from low- and middle-income countries [23, 24]. The practice of discontinuing antibiotics when a person feels better has been reported from various countries e.g. United Kingdom (UK) . A study in Nagpur, India  found that constraints of poverty is the major driving force for self-medication with antibiotics. It was not considered necessary to get a new prescription and thus pay a consultation fee when a doctor had previously recommended the drug for a similar complaint . The conclusion of the study was that it is important to improve physician and consumer knowledge and behaviour to use antibiotic drugs more rationally. Our study, which took place in Orissa, a socioeconomically more disadvantaged area in comparison to other Indian states, also suggests that poverty is the major driving-force for use of leftover medicines, incomplete courses and self-medication with antibiotics. On the other hand, a comparative study from eleven (economically advanced) European countries  indicates that a lack of awareness and an attitude towards situational use of antibiotics are contributors for irrational use of antibiotics.
Healthcare facilities and professional attitudes
According to previous studies from India by Basu et. al.  and Patel et. al., poor socioeconomic status, overcrowding of patients, inadequate prescription, overprescribing and improper selection of antibiotics are the major reasons behind resistance development, which was also viewed by our interviewees. Apart from this, our participants also perceived that improper diagnosis and inadequate prescription due to a lack of infrastructure and irrational prescription by unauthorized practitioners are also responsible for resistance development. This observation is similar to the findings of Kumar et. al. , who found that healthcare facilities with better infrastructure and prescribers with higher education and specialisation are associated with low antibiotic prescription. A previous study in UK showed that education on antibiotic prescribing and resistance at undergraduate and graduate education level is likely to enhance the quality of antibiotic prescribing . The participants in our study suggested that as unauthorized practitioners serve patients in remote areas, where the availability of trained prescribers is virtually nonexistent, training them might benefit public health.
The participants also offered a view that monitoring resistance patterns at the local level and making available this data to local prescribers may help appropriate empirical therapy. They also felt that information about and awareness of what constitutes prudent use of antibiotics given to practitioners routinely, might help reduce unnecessary antibiotic use and hence prevent resistance development. Our participants, especially the drug dispensers perceived that supplier incentives to the prescribers, is one of the factors responsible for higher antibiotic prescription rate. A study in China , in addition to the financial incentives to the prescribers, also identified fee-for-service treatment as a main driver of antibiotic overuse. This was not mentioned by our interviewees.
Antibiotic use in dairy animals
Studies have documented the presence of antibiotics in milk from dairy animals [33, 34]. The widespread use of antibiotics in dairy animals might also lead to the emergence of antibiotic resistant bacterial strains in their milk , something our participants also perceived as possible.
Ineffective law enforcement
In India, state governments have adopted central government guidelines on policies and programmes for healthcare development, and the state of Orissa adopted a policy on rational drug use in 1997 . Previous studies in India and other countries found that ineffective law enforcement increased the availability of fake or substandard medicines  and also availability of antibiotics without authorized prescription [26, 37, 38]. Our interviewees perceived such an issue to be existent in Orissa. A study from nine African countries suggests that, since most people purchase their drugs from drug dispensers due to lack of healthcare facilities, educating drug dispensers about rational drug use would probably be beneficial for public health in low-income countries . It is likely that enforcement of the law forbidding sale of antibiotics without a prescription from a qualified allopathic prescriber would reduce the total amount of antibiotics used. Awaiting a situation where there are enough qualified prescribers to enforce the legislation fully, education for all types of providers (as they are anyway prescribing antibiotics) would be a way to decrease the improper use of antibiotics. Our interviewees also suggest that a law dissuading the use of antibiotics and promoting the use of probiotics as a growth promoter in poultry is also needed.
After the United Nations Conference on the Human Environment in Stockholm in 1972, India passed the Environmental (Protection) Act in 1986. It provides for "the protection and improvement of environment and the prevention of hazards to human beings, other living creatures, plants and property". There is need for effective enforcement of this law to protect our environment from pharmaceutical waste.
A qualitative approach is the preferred method to explore an emerging concept - in this case the relationship between antibiotic use, resistance development and the environment. In order to improve the trustworthiness of our study, we used data triangulation during the analysis. Data was collected from different healthcare professionals including allopathic doctors, veterinarians and drug dispensers. The informants were from different geographical areas and socioeconomic environments, in this case proximity to sea/inland areas and urban/rural environments. During the coding procedure, both Oriya and English versions of the transcripts, and in some complex cases, tape recorded data, were used simultaneously in order to avoid misinterpretation of the full meaning. The authors of this study were from different educational backgrounds and countries, and each one brought a unique perspective to the study, enhancing its conformability. In the analyses, this factor served to broaden the interpretation and the final result is a negotiated outcome.